Farrish v. Commissioner of Social Security

Filing 23

MEMORANDUM OPINION. Signed by Magistrate Judge Joel C. Hoppe on 3/30/17. (hnw)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF VIRGINIA
Charlottesville Division
WENDY L. FARRISH,
Plaintiff,
v.
COMMISSIONER OF
SOCIAL SECURITY,
Defendant.

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Civil Action No. 3:15-cv-70
MEMORANDUM OPINION
By:
Joel C. Hoppe
United States Magistrate Judge

Plaintiff Wendy L. Farrish asks this Court to review the Commissioner of Social
Security’s (“Commissioner”) final decision denying her applications for disability insurance
benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social
Security Act (the “Act”), 42 U.S.C. §§ 401–434, 1381–1383f. The case is before me by the
parties’ consent under 28 U.S.C. § 636(c)(1). ECF No. 9. Having considered the administrative
record, the parties’ briefs, and the applicable law, I find that the Commissioner’s decision is not
supported by substantial evidence and therefore REMAND the case for further administrative
proceedings.
I. Standard of Review
The Social Security Act authorizes this Court to review the Commissioner’s final
decision that a person is not entitled to disability benefits. See 42 U.S.C. § 405(g); Hines v.
Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). The Court’s role, however, is limited—it may not
“reweigh conflicting evidence, make credibility determinations, or substitute [its] judgment” for
that of agency officials. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Instead, the Court
asks only whether the Administrative Law Judge (“ALJ”) applied the correct legal standards and
whether substantial evidence supports the ALJ’s factual findings. Meyer v. Astrue, 662 F.3d 700,
704 (4th Cir. 2011).
1

“Substantial evidence” means “such relevant evidence as a reasonable mind might accept
as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). It is
“more than a mere scintilla” of evidence, id., but not necessarily “a large or considerable amount
of evidence,” Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence review takes
into account the entire record, and not just the evidence cited by the ALJ. See Universal Camera
Corp. v. NLRB, 340 U.S. 474, 487–89 (1951); Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir.
1984). Ultimately, this Court must affirm the ALJ’s factual findings if “conflicting evidence
allows reasonable minds to differ as to whether a claimant is disabled.” Johnson v. Barnhart, 434
F.3d 650, 653 (4th Cir. 2005) (per curiam) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir.
1996)). However, “[a] factual finding by the ALJ is not binding if it was reached by means of an
improper standard or misapplication of the law.” Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir.
1987).
A person is “disabled” if he or she is unable to engage in “any substantial gainful activity
by reason of any medically determinable physical or mental impairment which can be expected
to result in death or which has lasted or can be expected to last for a continuous period of not less
than 12 months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a),
416.905(a). Social Security ALJs follow a five-step process to determine whether an applicant is
disabled. The ALJ asks, in sequence, whether the applicant (1) is working; (2) has a severe
impairment; (3) has an impairment that meets or equals an impairment listed in the Act’s
regulations; (4) can return to his or her past relevant work based on his or her residual functional
capacity; and, if not (5) whether he or she can perform other work. See Heckler v. Campbell, 461
U.S. 458, 460–62 (1983); 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The applicant bears the

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burden of proof at steps one through four. Hancock, 667 F.3d at 472. At step five, the burden
shifts to the agency to prove that the applicant is not disabled. See id.
II. Procedural History
Farrish applied for DIB and SSI on November 1, 2011, alleging disability caused by
rheumatoid arthritis, irritable bowel syndrome (“IBS”), and Graves’ disease. Administrative
Record (“R.”) 66, 76, ECF No. 11. At the time of her alleged onset date of December 1, 2007, 1
she was thirty-eight years old, R. 66, 76, and had most recently worked as a school bus driver, R.
73, 83. Disability Determination Services (“DDS”), the state agency, denied her claims at the
initial, R. 66–74, 76–84, and reconsideration stages, R. 86–95, 97–106. On September 19, 2013,
Farrish appeared with counsel at an administrative hearing before ALJ Brian P. Kilbane, at
which time the ALJ heard testimony from Farrish and Casey Vass, a vocational expert (“VE”).
R. 46–65.
ALJ Kilbane denied Farrish’s claims in a written decision issued on October 25, 2013. R.
23–40. He found that Farrish had severe impairments of fibromyalgia, inflammatory arthritis,
degenerative disc disease, and inflammatory bowel disease (“IBD”). 2 R. 26. Farrish’s

1

Farrish initially alleged an onset date of May 1, 2009. Id. At her administrative hearing, she asked to
reopen an earlier application for benefits and amend her alleged onset date to December 1, 2007, which
she claimed was the date she stopped working. R. 63–64. Although the ALJ did not expressly state
whether he granted this request, his written opinion considers whether Farrish was disabled as of the
amended onset date. See generally R. 23–40. Likewise, for purposes of this Memorandum Opinion, I will
regard the amended onset date as the proper starting point for Farrish’s alleged period of disability.
2

IBD and IBS are distinct ailments. IBS “is a common disorder that affects the large intestine” and
produces symptoms such as “cramping, abdominal pain, bloating, gas, diarrhea[,] and constipation,” but
does not often lead to severe symptoms or cause damage to the bowel tissue. See Irritable Bowel
Syndrome: Definition, Mayo Clinic (July 31, 2014), http://www.mayoclinic.org/diseasesconditions/irritable-bowel-syndrome/basics/definition/con-20024578. By contrast, IBD, which includes
Crohn’s disease and ulcerative colitis, produces more significant symptoms and “can be debilitating and
sometimes leads to life-threatening complications.” See Inflammatory Bowel Disease: Definition, Mayo
Clinic (Feb. 18, 2015), http://www.mayoclinic.org/diseases-conditions/inflammatory-boweldisease/basics/definition/con-20034908; see also IBD & IBS: Q&A, Cleveland Clinic (Mar. 14, 2012),

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impairments of Graves’ disease, anxiety disorder, and affective disorder were found to be
nonsevere. R. 26–27. The ALJ next determined that none of Farrish’s impairments, alone or in
combination, met or medically equaled the severity of a listed impairment. R. 27–28.
As to Farrish’s residual functional capacity (“RFC”), the ALJ found that she could
perform light work 3 with up to six hours of sitting and six hours of standing or walking in an
eight-hour day; unlimited balancing; frequent stooping, kneeling, crouching, and climbing of
ramps or stairs; and occasional crawling and climbing of ladders, ropes, or scaffolds. R. 28–37.
He also determined that Farrish would need a restroom facility available in her place of work. Id.
Based on this RFC and the VE’s testimony, the ALJ found that Farrish could perform her past
relevant work as a cashier and a receptionist, or alternatively, could perform other work existing
in significant numbers in the national and regional economies, including hand packer, laundry
worker, and office assistant. R. 38–39. He therefore concluded that Farrish was not disabled. R.
39. The Appeals Council denied Farrish’s request for review, R. 1–3, and this appeal followed.
III. Facts
A.

Relevant Medical Records
Farrish’s treatment notes date back to February 2003. R. 614–17. Prior to her alleged

onset date, she received periodic treatment (including inpatient hospitalization) for a variety of
gastrointestinal (“GI”) symptoms such as diarrhea, abdominal pain, nausea, and rectal bleeding.
See R. 614–17 (Feb. 21–24, 2003), 398–405 (Sept. 7, 2006), 438 (Oct. 21, 2006; Jan. 19, 2007),
http://my.clevelandclinic.org/health/articles/ibd-and-ibs-qanda (explaining differences between IBS and
IBD).
3

“Light” work involves lifting no more than twenty pounds at a time, but frequently lifting objects
weighing ten pounds. 20 C.F.R. §§ 404.1567(b), 416.967(b). A person who can meet these lifting
requirements can perform light work only if she also can “do a good deal of walking or standing, or do
some pushing and pulling of arm or leg controls while sitting.” Hays v. Sullivan, 907 F.2d 1453, 1455 n.1
(4th Cir. 1999).

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380–88 (Jan. 17, 2007), 441–42 (Jan. 30, 2007), 437 (Feb. 23, 2007). Treatment notes from her
February 2003 hospitalization state that Farrish had been diagnosed with Crohn’s disease two
years earlier, but this had not been confirmed by colonoscopy or biopsy. R. 614–16. Imaging of
her abdomen and pelvis during this period revealed generally normal findings. See R. 425 (Feb.
24, 2004), 423 (June 11, 2004), 418–20 (Sept. 7, 2006), 411 (Sept. 8, 2006). But see R. 392 (Jan.
17, 2007, pelvic CT scan findings compatible with inflammatory enteritis, with primary
consideration of Crohn’s disease), 464–66, 469–70 (Jan. 30, 2007, colonoscopy revealing ileitis,
proctitis, and internal hemorrhoids, and biopsies taken during colonoscopy, showing no acute
ileitis or colitis, but focal ulceration with inflammatory exudates noted in rectal sample). Farrish
was also evaluated during this time for anxiety, see R. 614–17 (Feb. 21–24, 2003);
musculoskeletal pains in her neck and knees, see R. 614–17 (Feb. 21–24, 2003), 421 (May 23,
2006), 378 (May 16, 2007); and hematuria, see R. 377 (Sept. 18, 2007), with no remarkable
findings.
Following her alleged onset date, on December 5, 2007, Farrish reported to the
emergency room at Prince William Hospital with complaints of nausea, vomiting, abdominal
pain in the right upper quadrant, and diarrhea. R. 361–69. An ultrasound revealed sludge in her
gallbladder, with no evidence of gallstones or gallbladder wall thickening, and mild dilation of
the common bile duct of uncertain etiology. R. 375. During a surgical consultation on December
14, Farrish explained that the pain in her right upper quadrant was different that the pain she
associated with Crohn’s disease, which she reported had not bothered her for quite some time
and was focused on her left side. R. 345–48. Because her signs, symptoms, and history of
gallstones were consistent with cholecystitis, Farrish underwent a laparoscopic cholecystectomy
(removal of the gallbladder). Id. On January 11, 2008, Farrish followed up with Arul Marathe,

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M.D., her gastroenterologist, and stated that she still had trouble keeping food down and
experienced continuing problems with abdominal pain and diarrhea. R. 435. 4
Over the next few months, Farrish complained of other symptoms as well. On January
22, she reported having blood in her urine, frequent urination, pain and swelling in her legs and
knees, lower back pain, and insomnia. R. 682–86. On February 26, she presented to Matthew
Swartz, M.D., for evaluation of her GI symptoms and large and small joint swelling and pain in
the lower extremities. R. 277–78. Dr. Swartz noted Farrish gained some relief from her joint
pains through nonsteroidal anti-inflammatory drugs (“NSAIDs”), but she limited her use of these
because they caused increased abdominal discomfort. R. 277. He also noted that in spite of her
symptoms, Farrish “continue[d] to work full time as a county school bus driver.” Id. 5 She was
tender in the right upper quadrant of her abdomen, exhibited trace crepitus in the knees, and had
slight tenderness on range of motion of the lower extremities. R. 277–78. Dr. Swartz opined that
these findings did not support inflammatory arthropathy, but he prescribed a low dose of
prednisone for trial use while Farrish awaited workup of her GI issues and abnormal liver
functioning. R. 278. On March 11, Dr. Swartz wrote a letter to Joseph Chambers, M.D., Farrish’s
primary care physician, explaining his doubt that Farrish’s musculoskeletal symptoms were
related to IBD because she did not exhibit overt synovitis. R. 276. He continued to recommend a
course of low-dose prednisone for diagnostic and potential long-term treatment purposes, and he
opined that Farrish’s GI condition may benefit from use of a biologic. Id.

4

Dr. Marathe’s handwritten notes are often difficult to read. Farrish interpreted these notes in a summary
of the evidence that she submitted to ALJ Kilbane. See R. 168–78.
5

At her hearing, Farrish maintained that she stopped working in December 2007, but took medical leave,
thus remaining on the county payroll as an employee, until May 2009. R. 53. Records obtained by the
state agency indicate earnings of $374.29 in 2008, but nothing in subsequent years. R. 189.

6

Farrish visited Dr. Marathe again throughout March, complaining of increasing
abdominal pain in the right upper quadrant, diarrhea, and nausea, and Dr. Marathe noted that her
blood work showed elevated liver enzymes. R. 432–34. Imaging taken on March 19 showed a
moderately dilated proximal common bile duct of indeterminate etiology. R. 327. On April 8, Dr.
Marathe performed endoscopic retrograde cholangiopancreatography (“ERCP”) and
sphincterotomy, revealing a dilated common bile duct with fusiform dilation, which raised a
question of possible choledochocele abnormality. R. 285. The following day, Farrish reported to
the emergency room with severe abdominal pain (distinct from her chronic pain in the right
upper quadrant) and was hospitalized for acute pancreatitis secondary to the ERCP. R. 311–25,
461–62. Her Crohn’s disease was noted to be relatively under control on Pentasa as she had not
had diarrhea or bloody bowel movements. R. 315. She was discharged on April 11 once her
pancreatitis resolved, with her chronic conditions diagnosed as sphincter of Oddi dysfunction
and Crohn’s disease. R. 309. Farrish visited Dr. Marathe again in late April and June, reporting
continued episodes of abdominal pain in the right upper quadrant and diarrhea. R. 429–30. She
also visited Dr. Swartz again on May 22, reporting that she had gotten some relief of her joint
pain from prednisone, but discontinued it because it caused problems with her diet and her
personality. R. 279. Dr. Swartz noted that Farrish’s labs were negative for evidence of
inflammatory process or immunologic disorder, and he deferred further treatment until her GI
issues had resolved, commenting that anti-inflammatory drugs could be effective in treating joint
pain, but would likely exacerbate the GI issues. Id.
On December 12, Farrish reported to the emergency room at the University of Virginia
(“UVA”) hospital with reports of diarrhea, nausea, vomiting, and exacerbation of her chronic

7

abdominal pain over the past week. R. 597–613. 6 She claimed that her stool frequency had
increased to ten to fifteen episodes per day, compared to her baseline of two to six per day. R.
598. The doctors mused that these symptoms must have “resolved upon arrival,” noting that she
had no bowel movements on the day of her admission and two bowel movements on the second
day of her stay and that she felt nauseous during her stay, but did not have any reports of emesis.
R. 600. On examination, Farrish was diffusely tender around her abdomen, particularly in the
right lower quadrant and epigastric area, but she did not exhibit guarding, rebound, distension, or
abnormal bowel sounds. R. 598, 600. CT imaging showed mild intrahepatic and extrahepatic
biliary ductal dilation and thickening of the sigmoid colon and bowel wall suggestive of the
sequelae of prior inflammatory change rather than an active inflammatory process. R. 599. The
location of her pain away from the right upper quadrant suggested that her biliary dilatation was
not the likely cause of pain. R. 600. Workup for IBD was ordered, but it was thought that IBS
was a more likely diagnosis. Id.
On December 22, 2009, Farrish began treating with Lien Dame, M.D., at UVA. R. 623–
25. She complained of depression, stating that she had trouble sleeping, was fatigued during the
day, had occasional unprovoked crying spells, was sometimes irritable, and dealt with stress at
home because of financial difficulties and taking care of her two young grandchildren. R. 623–
24. She also complained about pain in her lower back on the right side that occasionally radiated
down her right leg, which she thought might be related to carrying her grandson around on her
hip. R. 624. She did not take Tylenol or ibuprofen for her pain because of problems with her
liver, but she did get relief from ThermaCare patches. Id. Dr. Dame prescribed a selective
6

Treatment notes from this visit state that Farrish had visited another hospital on December 8, where she
was told she had pancreatitis and was given Percocet and an antibiotic. R. 602. They also note that an
MRI was taken on October 28 and a partial colonoscopy was performed in November. R. 598–99. No
direct documentation of these encounters appears in the record.

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serotonin reuptake inhibitor (“SSRI”) for Farrish’s depression and Aleve for her back pain. R.
625.
Dr. Dame also noted that Farrish was being followed for Graves’ disease by Christine
Eagleson, M.D., in UVA’s Endocrinology Department, and her GI issues were being followed by
Dr. Brian Behm in Digestive Health. R. 624–25. 7 Farrish’s Graves’ disease was status post
radioactive iodine ablation in April 2009, with resulting hypothyroidism, and she was awaiting
the results of a recent blood test. Id. With regard to her digestive problems, Dr. Dame noted that
Farrish’s previous diagnosis of Crohn’s disease had been modified to IBS after a series of
colonoscopies were negative for Crohn’s, and she ordered additional blood work to follow up on
Farrish’s history of abnormal liver function tests. Id. Almost one month later, Farrish was again
evaluated by Dr. Dame and Joanne Coleman, N.P., for severe abdominal pain in the left upper
quadrant. R. 622–23. She was referred to the emergency room at UVA, id., but there is no
indication in the record as to whether Farrish followed through on this referral.
Farrish followed up with Dr. Eagleson for treatment of her Graves’ disease on April 14,
2010. R. 618–19. She was taking levothyroxine for treatment of hypothyroidism. R. 618. Farrish
did not endorse hyperthyroid symptoms, but she did complain of some possible hypothyroid
symptoms, including weight gain, constipation, cold intolerance, and dry skin. Id. Nonetheless,
findings on physical examination were normal, and Dr. Eagleson noted that clinically Farrish
appeared to be euthyroid. R. 618–19. Farrish does not appear to have treated with Dr. Eagleson
again after this date, and on April 14, 2011, Dr. Eagleson mailed Farrish a letter (which was
returned undelivered) dismissing her from treatment with the Endocrinology Department. R.
585–86.
7

The record does not include treatment notes from Dr. Eagleson prior to this date or any treatment notes
from Dr. Behm.

9

From August 26 to 29, 2010, Farrish was hospitalized for fever, nausea, vomiting, and
dysuria related to a complicated urinary tract infection (“UTI”). R. 594–95. 8 She was found to
have sepsis secondary to possible pyelonephritis and was treated with IV fluids and antibiotics.
R. 594. When she followed up with Dr. Dame on September 9, she was asymptomatic as to her
kidneys, but she stated that she had been very fatigued since being discharged from the hospital.
R. 594–95.
Farrish visited Dr. Dame again several times over the next few months for treatment of
her back pain. See R. 592–93 (Oct. 14, 2010), 589–91 (Mar. 17, 2011), 586–88 (Apr. 14, 2011);
see also R. 584–85 (incomplete, unsigned, and undated report that Farrish attributes to a visit
with Dr. Dame in May 2011, see R. 172). She complained of pain in her right lower and upper
back and in her neck, along with joint pains in her legs, arms, and hips. R. 584, 587, 589, 593.
Physical examination findings were mostly normal, although she occasionally exhibited limited
range of motion and tenderness. R. 584–85, 587–88, 590, 593. Dr. Dame diagnosed Farrish with
fibromyalgia, R. 588, and, after noting that multiple medications did not help or were not
tolerated, referred Farrish to pain management and recommended an exercise program, R. 585.
Imaging of her hands, feet, and hips taken during the summer of 2011 showed minimal
narrowing of the bilateral interphalangeal joints, normal appearing sacroiliac joints with an
arthritic assimilation joint on the left, and no evidence of arthritis, but possible osteopenia, in the
feet. R. 490, 495–96.
On October 17, 2011, Farrish visited with Nandini Chhitwal, M.D., a rheumatologist, for
evaluation of her joint pains. R. 525–27. Dr. Chhitwal noted that Farrish had recently started
taking Plaquenil, which provided some relief from her hand pains, but she stopped taking this

8

The record does not contain treatment notes from this hospitalization.

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after some time because it exacerbated her GI symptoms. 9 R. 525. Dr. Chhitwal suspected that
Farrish had seronegative rheumatoid arthritis, but was reluctant to start her on any new
medications until she had a GI workup. R. 527.
On October 26, she visited with Jin H. Park, M.D., a gastroenterologist, complaining of
abdominal pain, bloating, and diarrhea. R. 481–83. Dr. Park arranged for Farrish to be evaluated
by CT scan, esophagogastroduodenoscopy (“EGD”), and colonoscopy; discontinued treatment
with NSAIDs; and prescribed Prevacid, Vicodin, and Carafate. R. 483. The CT scan, taken two
days later, was negative for any abnormalities in the abdomen or pelvis. R. 511. The EGD and
colonoscopy, performed in February 2012, yielded findings of erythema in the whole stomach
compatible with moderate gastritis, erythema in the first part of the duodenum compatible with
mild duodenitis, normal mucosa in the terminal ileum and whole colon, and hemorrhoids in the
colon. R. 791–802.
In December 2011, Farrish experienced abnormal urinary frequency and was treated for
UTI and likely pyelonephritis. See R. 568–71, 666–69. On examination, she exhibited tenderness
in her abdomen, back, and costovertebral angle (“CVA”). R. 569, 668–69. Her UTI resolved, but
in January 2012 she still experienced back pain and exhibited abdominal and CVA tenderness. R.
663–65. On February 27, Farrish visited Dr. Dame again for treatment of her depression and
fibromyalgia. R. 660–62. She reported that she had resumed taking Plaquenil, which provided
some relief, and she wanted to switch to a new SSRI because the current one irritated her
stomach. R. 660. She appeared fatigued, but otherwise exhibited normal signs on examination,
and her medications were adjusted. R. 661–62.

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Farrish appears to have resumed taking Plaquenil by November, and as a result, blood tests were
positive for benign neutropenia. See R. 537–40. She had discontinued this medication again by February
2012 because it aggravated her nausea and diarrhea. See R. 642–44.

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On April 6, Farrish reported to the emergency department at Culpeper Regional Hospital
(“Culpeper”) complaining of sharp, moderately severe pain in her upper abdomen and diarrhea
over the past four days. R. 718–22. She appeared uncomfortable and was moderately tender
around the epigastrium and upper quadrants of the abdomen. R. 719. Her labs were normal and
her CT scan showed a prominent common bile duct, which was not thought to be related to her
symptoms. R. 720–21. She followed up five days later with Darren Baroni, M.D., a
gastroenterologist, with continuing complaints of abdominal pain and notable tenderness in the
epigastrium and right upper quadrant. R. 803–04. Dr. Baroni and Dr. Park doubted that a stone
was present and scheduled a hepatobiliary iminodiacetic acid (“HIDA”) scan to rule out
sphincter of Oddi dysfunction. R. 804. The HIDA scan, performed in June, produced findings
not felt to correspond to sphincter of Oddi dysfunction. R. 812.
Farrish returned to Dr. Chhitwal on July 10, complaining of pains in her hands, feet, and
knees with morning stiffness and swelling in the knees. R. 687–90. She reported that she had
been taking Plaquenil daily since April and took ibuprofen for pain. R. 688. She stated that she
had recently been diagnosed with severe IBS and referred to a pain specialist, but also stated that
she refused her pain specialist’s offer of an injection in her back and that her nausea and diarrhea
were stable. R. 687–88. On examination, she had full range of motion throughout, no synovits,
and good hand grip, but was tender to palpation over the small joints of the hands and feet and
had 4/18 tender points (bilateral hips and upper back). R. 689. Dr. Chhitwal recommended
continuing with Plaquenil. R. 690. The next day, a rheumatoid arthritis series of X-rays showed
no significant arthritic or degenerative change in the hands, wrists, or feet, but mild osteopenia in
the feet. R. 693–95. The same day, she visited Dr. Park and reported that her GI symptoms were

12

partially controlled with Carafate and Prilosec, and Dr. Park referred her to another pain
management specialist. R. 814–15, 822–24.
On October 23, Farrish complained of back pain and dysuria, but lab work did not show
evidence of UTI. R. 787–88. On December 11, she returned to Dr. Chhitwal, stating that
Plaquenil had helped with her joint pains and stiffness, but that these had returned after she went
off the medication for the past couple weeks. R. 702–06. She also reported that she was
alternating ibuprofen and Tylenol three or four times per day. R. 703. Her GI symptoms were
stable. Id. On examination, she had full range of motion throughout, no synovitis, good hand
grip, and tenderness to palpation over the small joints of the hands and feet. R. 704. Dr. Chhitwal
increased her dosage of Plaquenil and recommended a trial of Duexis, an NSAID. R. 706. Ten
days later, she visited Dr. Baroni with complaints of pain in the right lower quadrant of her
abdomen, which she explained was different from her usual chronic pain, and several episodes of
diarrhea per day. R. 825–26. On examination, she exhibited mild discomfort to deep palpation in
the bilateral lower quadrants. R. 826. Dr. Baroni suspected that Farrish’s symptoms were an
exacerbation of IBS, and he declined her request for Vicodin, but recommended peppermint oil
for spasms. Id.
On February 15, 2013, Farrish reported to the emergency department at Culpeper
complaining of persistent dysuria, suprapubic pain, right flank pain, subjective fevers, chills, and
persistent nausea. R. 739–44. She had visited another physician several days earlier and was
given antibiotics for UTI, but these did not improve her symptoms. R. 739. On examination, she
exhibited suprapubic and CVA tenderness. R. 741. A CT scan showed no acute abnormality
involving the abdomen or pelvis. R. 744. She was diagnosed with acute persistent UTI and early
right pyelonephritis, prescribed hydrocodone, and continued on antibiotics. R. 743.

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Farrish visited Dr. Chhitwal on April 8, complaining of pain in her hands, feet, and neck.
R. 711–15. She reported that she was taking Plaquenil, which she tolerated “okay”; alternating
ibuprofen and Tylenol; and taking Phenergan for nausea, which was stable. R. 712. She also
reported that nobody was managing her fibromyalgia anymore and that she was taking fluoxetine
for anxiety, which helped her sleep. Id. On examination, she had full range of motion throughout,
no synovitis, and good hand grip. R. 713. She was tender over the left fourth and right third
proximal interphalangeal joints and all metatarsophalangeal joints, and she was positive for 9/18
tender points (bilateral ankles, right hip, bilateral anterior chest, and upper and lower back). Id.
Dr. Chhitwal opined that these findings were benign from an inflammatory standpoint, but also
found that Farrish’s fibromyalgia pain was sub-optimally controlled, for which he recommended
that she switch from fluoxetine to Cymbalta. R. 715.
On May 29, Farrish presented to the emergency department at Culpeper for evaluation of
pain in her right lower back. R. 750–53. She exhibited decreased range of motion of her back on
examination, but was nontender and had normal reflexes, full strength, and negative straight leg
raise. R. 751–52. She was diagnosed with pain originating in the right sacroiliac joint and
discharged with prescriptions for prednisone and Percocet. R. 752–53. She returned to the
emergency department on June 23, complaining of pain in the right upper quadrant of her
abdomen and of having trouble keeping food down. R. 754–58. She was tender in her right upper
quadrant on examination, but otherwise exhibited normal signs. R. 755–56. A CT scan showed
non-obstructive bowel gas pattern and no abnormal soft tissue calcifications. R. 761. She was
discharged with prescriptions for belladonna alkaloids with phenobarbital and Zantac. R. 757–
58.

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Farrish followed up with Tinatin Khizanishvili, M.D., a gastroenterologist, on June 28,
complaining of difficulty swallowing food and pills. R. 836–37. On examination, she had mild
tenderness in the epigastrium and mild distension of the abdomen. R. 837. Dr. Khizanishvili
assessed dysphagia, possibly caused by peptic stricture or other mucosal lesion, and IBS with
chronic diarrhea. Id. She underwent an EGD on July 1, which revealed gastritis in the body and
antrum of the stomach, esophageal spasm in the distal esophagus, esophagitis at the
gastroesophageal junction, and Schatzki’s ring at the gastroesophageal junction. R. 845–47.
Biopsies of samples taken during the procedure were positive for mild, chronic gastritis and
mild, chronic inflammation, but were otherwise benign. R. 848. The final treatment note in the
record is from an August 28 visit with Dr. Park. R. 852–54. Dr. Park noted that Farrish had “a
systemic autoimmune process” which caused vitiligo, Graves’ disease, and arthralgias. R. 852.
Farrish still experienced diarrhea and nausea daily. Id. Examination findings were normal, and
she was continued on her medications for reflux and dysphagia. R. 853.
B.

Opinion Evidence
The record does not include medical opinions from treating physicians or consulting

examiners. Instead, the only opinions in the record are those completed by DDS reviewing
experts. On January 24, 2012, as part of the initial review of Farrish’s claim, DDS reviewer
Sandra Francis, Psy.D., assessed Farrish’s mental functioning, finding that she had no
restrictions of activities of daily living, no difficulties in maintaining social functioning, and mild
difficulties in maintaining concentration, persistence, or pace. R. 69–70. The same day, William
Amos, M.D., assessed her physical functioning. He found that Farrish could lift or carry twenty
pounds occasionally and ten pounds frequently; stand and/or walk for six hours and sit for six
hours in an eight-hour workday; frequently balance, stoop, kneel, and crouch; and occasionally

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crawl and climb ramps, stairs, ladders, ropes, and scaffolds. Additionally, she should avoid
concentrated exposure to vibration and hazards. R. 71–73.
On reconsideration three months later, Bryce Phillips, Psy.D., opined that Farrish’s
anxiety and affective disorders were non-severe and she had mild restriction of activities of daily
living, mild difficulties in maintaining social functioning, and mild difficulties in maintaining
concentration, persistence, or pace. R. 91. DDS expert Luc Vinh affirmed Dr. Amos’s physical
RFC determination, except he found that Farrish was unlimited in her ability to balance, could
frequently climb ramps or stairs, and had no environmental limitations. R. 92–93.
C.

Farrish’s Submissions and Testimony
As part of her disability applications, Farrish submitted a function report on January 10,

2012. R. 215–22. She explained that on good days, she could do laundry, straighten up the
kitchen, and take care of her grandsons if she felt “up to having them.” R. 215–16. On bad days,
however, she would only move between the bed and the couch. R. 215. Her children helped her
take care of the dog. R. 216. Her impairments prevented her from being able to work, clean, do
yardwork, garden, carry her grandchildren, cook, and bake, and she did not sleep well at night.
Id. She could make simple meals, drive a car, and go outside occasionally. R. 217–18. She
shopped for groceries twice per month and could handle money. R. 218–19. She spoke with her
daughters and friends on the phone several days each week, but her impairments made her less
social than she used to be. R. 219–20. Her impairments affected her ability to lift, squat, bend,
stand, sit, climb stairs, complete tasks, and use her hands. R. 220. She could pay attention well
and follow written instructions, but she had to take notes to follow spoken instructions. Id. She
got along well with authority figures and handled stress okay, but she did not like changes in
routine. R. 221.

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At her administrative hearing, Farrish testified that she lived in a three-story home, but
stayed on the middle floor because she had difficulty going up and down the stairs. R. 51. She
last drove for work in 2007 and last drove a car privately in 2011 when she stopped driving
because of difficulty with her concentration and vision. R. 51–52. Around the time she stopped
working, she experienced constant abdominal pain, diarrhea, nausea, vomiting, and fatigue, and
she had to use the restroom six to seven times during the day for ten to thirty minutes at a time.
R. 52, 55–56. Her medications for arthritis, Graves’ disease, and vitiligo worsened her GI
symptoms and fatigue, and her symptoms limited her ability to concentrate throughout the day.
R. 54, 56.
IV. Discussion
On appeal, Farrish challenges the ALJ’s determination of her RFC—the most she can do
on a regular and continuing basis despite her impairments, 20 C.F.R. §§ 404.1545(a), 416.945(a);
SSR 96-8p, 1996 WL 374184, at *1 (July 2, 1996). Her brief, ECF No. 15, is highly vague as to
the nature of her objections. Most arguments take the form of legal boilerplate, and she does not
cite to any part of the record in support of her contentions. Nonetheless, considering these
objections along with the errors evident on the face of the ALJ’s opinion, I find that remand is
required.
A.

Function-by-Function Analysis
Farrish primarily objects to the ALJ’s failure to perform a function-by-function analysis

of her work-related limitations, particularly regarding the number of times she would need to use
the restroom each day and her inability to stay on task. Pl. Br. 2–4. In assessing a claimant’s
RFC, the ALJ “must first identify the individual’s functional limitations or restrictions and assess
his or her work-related abilities on a function-by-function basis” before the RFC may be stated

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“in terms of the exertional levels of work, sedentary, light, medium, heavy, and very heavy.”
Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting SSR 96-8p, 1996 WL 374184, at
*1). The ALJ’s RFC assessment “must include a narrative discussion describing” how specific
medical facts and nonmedical evidence “support[] each conclusion” in the RFC finding. Id.
(quoting SSR 96-8p, 1996 WL 374184, at *7). Mascio does not set out “a per se rule requiring
remand when the ALJ does not perform an explicit function-by-function analysis.” Id. Instead,
remand should be considered “where an ALJ fails to assess a claimant’s capacity to perform
relevant functions, despite contradictory evidence in the record, or where other inadequacies in
the ALJ’s analysis frustrate meaningful review.” Id. (quoting Cichocki v. Astrue, 729 F.3d 172,
177 (2d Cir. 2013)). Thus, the ALJ need not have explicitly set forth a detailed analysis for each
of Farrish’s functional abilities as long as his conclusions are ascertainable from his narrative
discussion and supported by the record.
As to Farrish’s GI symptoms, the ALJ determined that the record did not support the
degree of severity she alleged. R. 36–37. He found that she appeared to have exaggerated some
of her symptoms, noting for instance that she had limited bowel movements after being admitted
to the hospital at UVA in December 2008, despite claiming that she had recently experienced ten
to fifteen episodes of diarrhea per day. Id. (citing R. 598–600). This incident, although
noteworthy, seems insufficient to support a finding that Farrish was exaggerating her symptoms,
especially considering her doctors’ suggestion that her symptoms had simply resolved by the
time she was admitted, see R. 600. Similarly, the ALJ found that Farrish’s admission to the
emergency department at Culpeper in April 2012 undermined her credibility because she did not
exhibit tenderness or vomiting during her stay, despite having complained of diarrhea and
abdominal pain. R. 37 (citing R. 718–28). This finding, however, ignores part of the same

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treatment note expressly stating that Farrish had abdominal tenderness on examination, R. 719, a
discrepancy which the ALJ did not address.
More critically, the ALJ’s evaluation of Farrish’s GI symptoms, based on two isolated
episodes during the relevant period, does not suggest that he considered the longitudinal record
as a whole. This raises particular concern here because the ALJ’s narrative discussion of the
record, R. 29–35, omits a significant portion of Farrish’s treatment history. For instance,
although Farrish’s GI impairment was chronic in nature and documented as far back as 2003, the
ALJ did not discuss any of the record evidence from before the alleged onset date. The narrative
discussion also leaves out many of the treatment notes from Dr. Marathe, see R. 429–36, several
notes from Dr. Dame, see R. 594–95, 622–23, and notes from Dr. Baroni, see R. 803–04, 825–
26, all of which pertained to Farrish’s complaints of abdominal pain, diarrhea, and nausea, which
were thought to be related to her IBS. Insofar as the ALJ’s opinion can be read to state that
Farrish did not need to use the restroom with any frequency beyond normal workplace
tolerances, these omissions significantly undermine the assumption that his analysis was based
on a comprehensive review of the record.
Likewise, the ALJ did not adequately evaluate the possible functional effects of Farrish’s
pain, particularly to the extent her pain was caused by fibromyalgia. This impairment “is defined
as ‘[a] syndrome of chronic pain of musculoskeletal origin but uncertain cause.’” Johnson v.
Astrue, 597 F.3d 409, 410 (1st Cir. 2009) (per curiam) (quoting Stedman’s Medical Dictionary,
at 671 (27th ed. 2000)). It is, by definition, a diagnosis of exclusion, see SSR 12-2P, 2012 WL
3104869, at *2–3 (July 25, 2012), and is typically not accompanied by objective findings, see
Sarchet v. Chater, 78 F.3d 305, 307 (7th Cir. 1996) (“[Fibromyalgia]’s symptoms are entirely
subjective.”). “The musculoskeletal and neurological examinations are normal in fibromyalgia

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patients, and there are no laboratory abnormalities.” Johnson, 597 F.3d at 410 (quoting
Harrison’s Principles of Internal Medicine, at 2056 (16th ed. 2005)). As a result, “[s]everal
courts of appeals have held that ALJs may not rely on the lack of objective findings in
discrediting a treating doctor’s opinion regarding the severity of a patient’s fibromyalgia,” and
“district courts in this circuit have recognized that a lack of objective findings is not a good
reason to discount a treating physician’s opinion regarding the existence or severity of a patient’s
fibromyalgia.” Ellis v. Colvin, No. 5:13cv43, 2014 WL 2862703, at *8 (W.D. Va. June 24, 2014)
(collecting cases).
Here, the ALJ found that fibromyalgia was a severe impairment, R. 26, and many of
Farrish’s symptoms were consistent with that disorder. See Stahlman v. Astrue, No. 3:10cv475,
2011 WL 2471546, at *6 (E.D. Va. May 17, 2011) (noting fibromyalgia is characterized by
“significant pain and fatigue, tenderness, stiffness of joints, and disturbed sleep”), adopted by
2011 WL 2470249 (E.D. Va. June 21, 2011). Despite acknowledging this, however, the ALJ
found that Farrish’s descriptions of her pain were less than fully credible because the pain did not
manifest through objective signs such as joint swelling, reduced range of motion, or diminished
strength. R. 36. The absence of such signs, however, does not necessarily detract from a
claimant’s allegations of severe fibromyalgia pain. See Preston v. Sec’y of Health & Human
Servs., 854 F.2d 815, 820 (6th Cir. 1988) (discussing fibrositis). Likewise, the fact that Farrish
was encouraged to exercise does not, as the ALJ suggested, discredit her claims of severe pain
from fibromyalgia. See Johnson, 597 F.3d at 412 (explaining that physical therapy and aerobic
exercise are appropriate treatments for fibromyalgia). Although a recommendation to exercise
may be probative of whether her movement and strength were significantly limited, it says

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nothing about Farrish’s other limitations (such as diminished concentration and ability to stay on
task) caused by her pain and related symptoms of fatigue and insomnia.
Some of the ALJ’s other reasons for discounting Farrish’s complaints of pain also ring
hollow. For instance, he cites to Dr. Swartz’s letter opining that Farrish’s musculoskeletal
symptoms were not likely related to her GI dysfunction. R. 36 (citing R. 276). That the etiology
of her pain was (at that time) uncertain, however, speaks little to whether her allegations of pain
were consistent with the record, particularly because the ALJ identified other impairments that
could have caused Farrish’s pain, including fibromyalgia, degenerative disc disease, and
rheumatoid arthritis, as severe, R. 26. Likewise, although the ALJ found that medications were
relatively effective in controlling Farrish’s pain, R. 36, this finding disregards the numerous
instances in the record in which Farrish stated that she could not tolerate NSAIDs and other pain
medications because they exacerbated her GI symptoms. If the ALJ intended to state that this
concern was no longer relevant because Farrish’s other symptoms had stabilized to the point she
could tolerate her medication, he did not clearly explain it. In addition, the ALJ’s finding that
Farrish claimed to be working full time as a bus driver in February 2008 (merely two months
after her alleged onset date) relates to only a small part of the relevant period, and thus does not
seem to be particularly germane to her allegations of pain throughout that entire period.
Moreover, she earned $374.29 in 2008, R. 190, which certainly does not suggest extensive work.
For these reasons, the ALJ’s evaluation of Farrish’s functioning, particularly as it relates to the
frequency of her need to use the restroom and the non-exertional effects of her pain, is not
supported by substantial evidence.
B.

Medical Opinions

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Farrish also contends that “the ALJ improperly rejected the findings and opinions of the
treating physicians.” Pl. Br. 4. As the Commissioner correctly observes, Def. Br. 10, ECF No.
22, this argument has no merit because the record does not include any medical opinions 10 issued
by Farrish’s treating physicians. By contrast, Farrish’s objection to the weight the ALJ gave the
DDS examiners, Pl. Br. 4, presents a closer issue. Farrish challenges the ALJ’s decision to give
considerable weight to the opinions rendered by the DDS experts on reconsideration, even
though those opinions, issued in April 2012, would not have reflected the entire treatment record,
which extends through August 2013. On its own, the ALJ’s decision to credit opinions that are
based on a review of less than the full record would not necessarily be in error. See Chandler v.
Comm’r of Soc. Sec., 667 F.3d 356, 361 (3d Cir. 2011) (“[B]ecause state agency review precedes
ALJ review, there is always some time lapse between the consultant’s report and the ALJ hearing
and decision.”). Here, however, the ALJ’s explanation of the reasons for his treatment of the
opinion evidence is puzzling. Although he found the reconsideration opinions to be fully
reflective of the record, he gave only partial weight to the DDS experts’ opinions rendered on
initial review in January 2012, on the grounds that those reviewers “did not have access to
subsequent medical evidence.” R. 37. The Court is unable to discern the ALJ’s rationale for
finding that the record was insufficient to form an opinion of Farrish’s functioning as of January
2012, but became adequate to do so by April 2012. On remand, the ALJ should clarify the
reasons for the weight given to the opinions in the record.
C.

Consultative Examination

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“Medical opinions are statements from physicians and psychologists or other acceptable medical
sources that reflect judgments about the nature and severity of [the claimant’s] impairment(s), including
[his or her] symptoms, diagnosis and prognosis, what [he or she] can still do despite impairment(s), and
[his or her] physical or mental restrictions.” 20 C.F.R. §§ 404.1527(a)(2), 416.927(a)(2).

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Farrish also contends that the ALJ should have ordered a consultative examination in
order to further supplement the record. Pl. Br. 2. The Commissioner must purchase a consultative
exam “when the evidence as a whole, both medical and nonmedical, is not sufficient to support a
decision on [the] claim.” Kersey v. Astrue, 614 F. Supp. 2d 679, 695 (W.D. Va. 2009) (quoting
20 C.F.R. §§ 404.1519a(b), 416.919a(b)). Although the Commissioner has a duty to develop the
record, the regulations require only that the “evidence be ‘complete’ enough to make a
determination regarding the nature and severity of the claimed disability, the duration of the
disability[,] and the claimant’s residual functional capacity.” Id. (citing Cook v. Heckler, 783
F.2d 1168, 1173 (4th Cir. 1986)). Thus, the Commissioner may properly decide not to purchase a
consultative exam “when the record contains sufficient information” to make these findings.
Johnson v. Astrue, No. 6:11cv9, 2012 WL 2046939, at *3 (W.D. Va. June 5, 2012).
Because I find that remand is necessary in this case for other reasons, I need not resolve
this issue here. I note, however, that an in-person examination of Farrish may prove helpful in
evaluating her functioning, as no such opinion currently exists in the record. I also note that the
current record appears to be incomplete, as it includes references to treatment visits, but no direct
documentation of those visits. See supra notes 7–9. If these records can be found, they may
provide a more complete picture of Farrish’s functioning during the relevant period.
V. Conclusion
For the foregoing reasons, I find that the Commissioner’s decision to deny Farrish’s
applications is not supported by substantial evidence. Accordingly, the Court will GRANT
Farrish’s Motion for Summary Judgment, ECF No. 14, DENY the Commissioner’s Motion for
Summary Judgment, ECF No. 21, REMAND this case pursuant to sentence four of 42 U.S.C. §

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405(g) for further administrative proceedings, and DISMISS this case from the Court’s active
docket. A separate order will enter.
The Clerk shall send certified copies of this Memorandum Opinion to all counsel of
record.
ENTER: March 30, 2017

Joel C. Hoppe
United States Magistrate Judge

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